13

Concluding Remarks and Discussion

In this session, the members of the planning committee reflected on the overall themes they perceived during the workshop. The sections below reflect the individual member’s thoughts and remarks.

PLANNING COMMITTEE REMARKS

Spero M. Manson, Ph.D.
University of Colorado Denver

In the short term, HRSA, particularly through the Office for the Advancement of Telehealth, can begin to task a number of its technical assistance and resource centers with activities such as further synthesis of the available evidence in the literature and assistance with respect to articulating the essential components of best practices. In the longer term, HRSA should convene a full study on telehealth—there is enough evidence available, and the timing is appropriate. The work of the Office for the Advancement of Telehealth could inform that study process, giving researchers a great foundation. While the workshop covered a breadth of topics, HRSA needs to carefully consider what specific priorities it would want such a study to address. Specificity in the statement of task will be critical to reaching desired goals.



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13 Concluding Remarks and Discussion In this session, the members of the planning committee reflected on the overall themes they perceived during the workshop. The sections below reflect the individual member's thoughts and remarks. PLANNING COMMITTEE REMARKS Spero M. Manson, Ph.D. University of Colorado Denver In the short term, HRSA, particularly through the Office for the Ad- vancement of Telehealth, can begin to task a number of its technical as- sistance and resource centers with activities such as further synthesis of the available evidence in the literature and assistance with respect to ar- ticulating the essential components of best practices. In the longer term, HRSA should convene a full study on telehealth--there is enough evidence available, and the timing is appropriate. The work of the Office for the Ad- vancement of Telehealth could inform that study process, giving research- ers a great foundation. While the workshop covered a breadth of topics, HRSA needs to carefully consider what specific priorities it would want such a study to address. Specificity in the statement of task will be critical to reaching desired goals. 125

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126 THE ROLE OF TELEHEALTH Sherilyn Z. Pruitt, M.P.H. Health Resources and Services Administration One theme that emerged over the workshop included an emphasis on the relationship between the patient and the provider; technology should not be seen as a barrier, but something that facilitates access for more pa- tients to interact with their providers. Similarly, the focus should be on the patient and not the technology. Also, there was a lot of discussion about the consideration of the site of service being where the provider is, instead of where the patient is. Another theme was to think about a more systematic way to implement telehealth across the country, so that every person can get appropriate care no matter where they are, and what that system might look like. While many people are working on their own roles, we need to take a step back and look at the system as a whole. Is there a way to accelerate getting knowledge into practice across the country, especially because technology changes at such a rapid pace? For example, Models That Work was a program that looked at effective community-based models. With grant funding, they were able to create rep- lication guides (e.g., what they did, how they did it) that other communities could download off the Internet. The communities then used government funding to contract directly with the models' designers to come help them adopt the program. As we look forward, other questions come to mind. Why do we not appreciate the evidence on telehealth that is already available? How can we increase the number of payers who reimburse for telehealth? How can we learn from what is happening in other countries? Thomas S. Nesbitt, M.D., M.P.H. University of California, Davis, Health System Questions arise when we try to think about what telehealth would look like if we did it right. What would a technology-enabled rural community look like? What would the services be? How would chronic disease and home health management work? How would it work when you go to your physician and find that you need specialty care? What would it look like when you go to the emergency department with a stroke, or you are in the intensive care unit? We are beginning to assemble all the pieces. We heard that the evidence is very strong in some areas, but we also heard there is an opportunity to do studies using a variety of methodologies, and we do not have to be ashamed that we do not use just one methodology for looking at telehealth and its benefits. However, we need to have a better way to pull together consensus of the evidence that is more accessible to people. It is not just policy makers

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CONCLUDING REMARKS AND DISCUSSION 127 who remain unaware of the evidence base, but perhaps also researchers who repeat studies because they do not know other studies exist. We also heard that there is an explosion in technology that is rapidly changing, and it is difficult to keep pace with this change. In many ways, consumers are going to push us in different directions than we might expect, and may come up with their own solutions. If we are not proactive, these solutions may not be the best. For example, we heard about websites with misinformation. Also, stakeholders can be great advocates for telehealth, including for the applications that we do not always think about, such as for public health. One of the most impressive things is the amount of enthusiasm and activity at the state level. In the current political climate, top-down "stick" approaches to health care from the federal government are not popu- lar. However, federal support for removing barriers in state-initiated ap- proaches, including Medicaid waivers, will be critical. If states come up with solutions (e.g., Medicaid reimbursement), it will be easier to make federal policy changes. The VA and IHS showed us that there are good models out there to serve rural communities. We need to figure out how to get their "lessons learned" out to the rest of the population. Kamal Jethwani, M.D., M.P.H. Partners Healthcare Center for Connected Health; Harvard Medical School The evidence base for telehealth is strong, but maybe this evidence is enough to prove that it works, but not enough to motivate adoption. As we go forward, an immediate next step is to come up with standards for what kind of evidence is needed (e.g., cost-effectiveness data, return- on-investment data) in order to accelerate adoption. Additionally, health care can be made more efficient with all the data that are being generated, such as for the application of big datasets to public health at the popula- tion level. Health care has been lagging behind other industries for a long time. A recent article by Atul Gawande in The New Yorker talked about how health care can be made as efficient as The Cheesecake Factory, which reduced waste by benchmarking the activity of their customers (Gawande, 2012). In health care we collect so much data (e.g., electronic medical records, patient-generated data, remote monitoring), there must be op- portunities to put these data together and make health care more efficient. Nina M. Antoniotti, Ph.D., M.B.A., R.N. Marshfield Clinic Vision for the future can sometimes be held captive to bureaucracy. Even within HHS, there can be a dichotomy of pushing for the latest tech-

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128 THE ROLE OF TELEHEALTH nologies while holding to old standards. How can we transform public policy? The vision of the ONC should help transform the policy thinking of other HHS agencies and help people receive care and interact with the health care system in the virtual space, from direct patient-to-provider consult to mobile applications. In terms of the evidence base, one question is, Are we making this too hard? In Wisconsin, telepharmacy was initiated under the physician practice model and against the will of the pharmacy boards. After pharmacists were brought in, they became convinced of the use of the technology just based on their experience, not academic research. As a result, public policy was changed. Telehealth-facilitated dialysis care started not because of a robust evidence base, but because a member of the U.S. Congress wanted it. How- ever, we need to develop a valid clinical trial design and validate the match controlled study design to be the gold standard for evaluating telehealth. Telehealth is about the people, not the process. Public policy should not place barriers based on assumptions. For example, we are mired in discussions of presuming to know what patients want. Furthermore, we need to establish the methodology that HHS would use to translate con- sumer momentum around mobile devices. Consumers push us to do things differently in health care, and we do it because it makes sense, has good outcomes, and engages patients. Finally, there should be an ongoing committee to help facilitate inte- grating technology-supported health care into evidence-based health care, public policy, and the mainstream. Karen S. Rheuban, M.D. University of Virginia Health System Many policy decisions need to be made at the state and federal levels. We need to broaden reimbursement at the federal and state levels in order to get providers on board, both in the current fee-for-service model as well as in payment reform models. Also, the rural requirement should be elimi- nated; many specialty providers are located in urban areas and we want them to support rural communities as well as their own communities. We have repeatedly heard about barriers due to licensure, credentialing and privileging, and scope of practice, which need to be addressed. For example, a new paradigm for "place of service" may help to eliminate regulatory barriers. We need to expand the availability of broadband service. More studies are needed on the value, proposition, and return on investment for telehealth. Finally, telehealth is about all of health care, and we need to collaborate with the specialty societies.

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CONCLUDING REMARKS AND DISCUSSION 129 REACTION AND DISCUSSION Moderator: Karen S. Rheuban, M.D. University of Virginia Health System An open discussion followed the planning committee members' re- marks. Audience members were able to give comments and ask questions of the planning committee members and workshop participants. The fol- lowing sections summarize the discussion session. Data and Evidence One participant talked about how to fast-track important studies in peer-reviewed journals. Another participant supported matched cohort group designs for research to prove the efficacy of telehealth. Another participant noted that telehealth needs to be integrated into the push for the adoption of electronic health records, creating meaningful use, and es- tablishing health information exchanges. He stated that face-to-face patient encounters already involve the examination of several data sources, and the use of health information technology could allow for the inclusion of sup- port mechanisms to help reduce medical errors and variation in care. He added that the sharing of data, in a secure and meaningful way, is improv- ing the continuity of care, decreasing overuse (e.g., unnecessary tests), and increasing efficiency. He further added that telehealth and health informa- tion exchange need to become global efforts. Consumers One participant remarked that the cost of gasoline may push consumers toward telehealth, especially if they have to travel long distances to receive health care services. Another participant added that telehealth technology is necessary to leverage solutions for reaching broader populations. He fur- ther added that in order to make any difference in health and health care, we need to change behaviors, so telehealth might be used for that as well. Workforce One participant remarked that there was not enough discussion of the kind of workforce that is needed to support telehealth in rural areas--either new types of providers or retraining of current providers. The participant added that more discussion is needed about scope of practice, and how providers work together. Nesbitt noted the funding that HRSA provides for health professions training and suggested incentives could be created for

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130 THE ROLE OF TELEHEALTH the inclusion of telehealth training in proposals. He added that exposure to telehealth is key to provider acceptance. Antoniotti stated that several educational models are already using distance education to a large degree, which could be used to train many professionals in telehealth technologies. Rheuban commented that HHS funded the Virginia Health Workforce Development Authority, and one of the grant projects they will support is the development of a certified telehealth technician program. She stated that health care providers need to understand what the technology can do, but do not need to operate the technologies, so a trained workforce can be developed to do this. Antoniotti disagreed, stating that in their model, providers were trained in how to use, fix, and maintain their own equipment, as this was much more efficient than calling in others to do it, and prevented abandonment of the technology. Rheuban responded that because most clinic providers are already overwhelmingly busy (and likely to be even busier after full implementation of the ACA), their vision is to train an on-site licensed practical nurse or certified nursing assistant to sup- port the telehealth technologies, thereby maximizing the efficiency of the primary care or specialty care providers. Medicaid One participant noted that Medicaid is a key player in telehealth be- cause of the numbers of individuals they cover, because of the high amount of expenditures, and because success with these populations will be the most difficult challenge. Nesbitt agreed that with Medicaid expansion, there will be tremendous pressure on the Medicaid managed care program. He noted that telehealth might be seen as a solution in states that are re- quired to show the ability to provide timely access to services for newly added populations. Telehealth might also help solve problems with lack of local providers, particularly specialty providers, who are willing to serve Medicaid populations, and provide more choice to patients.